ALL sections must be completed to be reviewed.
Also, please download and submit a signed medical release form (PDF) from your diagnosing physician.
If you choose, you may also download the PATH application (PDF) and your completed medical release form, and fax or mail them to us.
Mailing Address
440 Louisiana St Ste 900
Houston, TX 77002
Fax
713-529-0780
Email
gr****@********as.org
To expedite your application, please attach copies of information listed below that applies to you.
Proof of Identification
- TX Driver’s License or TX ID card or Passport
AND - Social Security Card or Birth Certificate (if no other documentation available)
Proof of Residence
- TX Driver’s License or TX ID with address matching your application
- Voter registration card with address matching your application
- Current utility bill with address matching your application (regardless of the name on the bill)
Income (Household)
- Four (4) most recent paycheck stubs
- If paid in cash, please provide a statement from employer verifying income
- If self-employed, provide current records or self-employment form
- Last year’s tax filing
- Current Social Security Award letter for both spouses and any children receiving
- Current Child Support Statements (actual checkd or court-ordered child support)
- Current proof of any fixed income such as: widow’s benefits, retirement, pension, dividend payments, unemployment benefits, worker’s compensation, etc.)
Verification of Other Assistance
- Current award/denial letter for Medicaid, TANF, SSI, Housing and Food Stamps, or any other assistance program
Resources
- Bank statement from checking and/or savings account
- Verification of stock, bond, or retirement accounts
- Upon receipt, your request will be reviewed in accordance with our chapter policies. You may be asked for further information prior to approving any requests.
- Depending on the availability of our current resources, we will consider limited financial assistance as directed by our policies.
- Approved funds will be paid directly to the vendor or service provider unless otherwise approved in advance.
- While we wish we could fund every person in need, our funds are limited and completing an application does not guarantee that we will be able to meet your request. We do our best to serve as many in need as possible.
- Items and services which have already been billed prior to grant approval will not be covered.
- The information you provide is confidential and will not be released to anyone without your written permission.
- If you have any questions regarding the forms or application process, please call our office at
- (713) 529-0126 or email us at gr****@********as.org.
